Provider Demographics
NPI:1770327561
Name:JOHNSON, MAKENZIE MARIE
Entity type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3632 MIDDLEFIELD DR APT B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-1762
Mailing Address - Country:US
Mailing Address - Phone:423-902-6436
Mailing Address - Fax:
Practice Address - Street 1:635 BARNHILL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5126
Practice Address - Country:US
Practice Address - Phone:317-274-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program